Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings

Methods for community-engaged data collection and analysis in implementation research

BACKGROUND

Community engagement is widely recognized as critical to successful and equitable implementation of evidence-based practices, programs, and policies. However, there are no clear guidelines for community involvement in data collection and analysis in implementation research.

METHODS

We describe three specific methods for engaging community members in data collection and analysis: concept mapping, rapid ethnographic assessment, and Photovoice. Common elements are identified from a case study of each method: 1) selection and adaptation of evidence-based strategies for improving adolescent HPV vaccine initiation rates in disadvantaged communities, 2) strategies for implementing medication for opioid use disorders among low-income Medicaid enrollees during natural disasters, and 3) interventions to improve the physical health of adults with severe mental illness living in supportive housing.

RESULTS

In all three cases, community members assisted in participant recruitment, provided data, and validated preliminary findings created by researchers. In the Photovoice case study, community members participated in both data collection and analysis, while in the concept mapping, community members also participated in the initial phase of organizing and prioritizing evidence-based strategies during the data analysis.

CONCLUSIONS

Community involvement in implementation research data collection and analysis contributes to greater engagement and empowerment of community members and validation of study findings. Use of methods that exhibit both scientific rigor and community relevance of implementation research also contributes to greater community investment in successful implementation outcomes. Nevertheless, the case studies point to the importance and efficiency of the division of labor embedded in community-engaged implementation research. Building capacity for community members to assume greater roles in obtaining and organizing data for preliminary analysis prior to interpretation is recommended.

Development of a Vaccine Advocacy Scale for Childhood Vaccines and Psychometric Evaluation: A Methodological Study

AIM

This study developed the Vaccine Advocacy Scale for childhood vaccines for adults and evaluated its psychometric properties.

METHOD

This methodological study involved 211 adults. A literature review was conducted to create the item pool of the scale, and 12 items were prepared. While evaluating the scale's psychometric properties, the researchers performed content validity, explanatory factor analysis (factor loadings of the items, eigenvalues of the sub-dimensions, and explained variance rates), confirmatory factor analysis (factor loadings and common fit indices), and criterion validity (predictive validity) in the validation phase. In the predictive validity assessment, the distribution of scores on the scale was examined according to some behaviours related to vaccine advocacy. Additionally, we analysed the item-total score correlation, Cronbach's alpha coefficient, and split-half test consistency in the reliability phase.

RESULTS

The study's calculated Kaiser-Meyer-Olkin value was 0.868, and Bartlett's test of sphericity resulted in significant results (X2 = 1724.166; p < 0.001). The explanatory factor analysis revealed that the items' factor loadings were between 0.451 and 0.949 and explained 58.29% of the total variance of the structure, which consisted of 12 items and two sub-dimensions. The confirmatory factor analysis found the factor loadings of the items between 0.62 and 0.85 and identified 'common fit indices' within acceptable ranges and close to the perfect fit values (X2/df, GFI, CFI, RMSEA, RMR, NFI, TLI and IFI were 1.906, 0.950, 0.952, 0.093, 0.059, 0.906, 940 and 0.953, respectively). The Cronbach's alpha value for the scale was 0.92, and the Spearman-Brown coefficient, Guttman's split-half coefficient, and split-half correlation coefficients were 0.843, 0.842 and 0.713, respectively. The study findings indicated that individuals who had talked to other parents about vaccines, recommended vaccinations, and communicated vaccine-related issues with medical professionals had significantly higher total scale scores (p < 0.005).

CONCLUSION

Considering the study findings and evaluations, the Vaccine Advocacy Scale was a valid and reliable measurement tool to assess adults' vaccine advocacy behaviour for childhood vaccines.

The Impact of an Educational Program on the Awareness and Knowledge of Human Papilloma Virus (HPV) Vaccine Among Secondary School Girls in Saudi Arabia

BACKGROUND

 The objectives were to assess the effectiveness of the educational program in enhancing students' understanding of the human papillomavirus (HPV) vaccine, correcting misconceptions, and increasing overall awareness. Additionally, the study aimed to identify factors influencing knowledge improvement and willingness to be vaccinated against HPV, including prior knowledge, information sources, session attendance, and school type.

METHODS

In this study, 148 participants were enrolled from secondary schools in Saudi Arabia, and data were collected through pre- and post-educational session assessments, logistic regression analyses, and qualitative investigations. Educational sessions focused on key aspects of the HPV vaccine, including its preventive benefits, administration details, and side effects, tailored to address common misconceptions and enhance understanding among students.

RESULTS

 The study revealed significant improvements in students' knowledge post-educational sessions, particularly in key areas such as cervical cancer prevention, gender recommendations, vaccine administration, and side effect awareness. Prior knowledge, information sources, session attendance, and school type significantly influenced knowledge enhancement and willingness to be vaccinated against HPV. The qualitative analysis provided additional insights into challenges, perceptions, and misconceptions surrounding HPV vaccination, underlining the significance of targeted education and cultural sensitivity in promoting vaccination uptake.

CONCLUSION

 The findings underscored the effectiveness of the educational intervention in enhancing HPV vaccine awareness, dispelling myths, and fostering informed decision-making among Saudi Arabian adolescent populations. The study emphasizes the critical role of tailored educational programs in correcting misconceptions, promoting accurate knowledge, and ultimately increasing vaccination acceptance for improved public health outcomes and disease prevention efforts. Ongoing efforts are essential to sustain and expand educational initiatives to enhance HPV vaccine understanding and adolescent uptake.

Use of concept mapping to inform a participatory engagement approach for implementation of evidence-based HPV vaccination strategies in safety-net clinics

BACKGROUND

Multiple evidence-based strategies (EBS) for promoting HPV vaccination exist. However, adolescent HPV vaccination rates remain below target levels in communities at high risk for HPV-associated cancers and served by safety-net clinics. Participatory engaged approaches are needed to leverage the expertise of community and clinical partners in selecting EBS relevant to their local context. We engaged concept mapping as a method to inform the adoption and adaptation of EBS that seeks to empower implementation partners to prioritize, select, and ultimately implement context-relevant EBS for HPV vaccination.

METHODS

Using 38 EBS statements generated from qualitative interviews and national HPV vaccine advocacy sources, we conducted a modified concept mapping activity with partners internal to safety-net clinics and external community members in two study sites of a larger implementation study (Greater Los Angeles and New Jersey), to sort EBS into clusters and rate each EBS by importance and feasibility for increasing HPV vaccination within safety-net clinics. Concept mapping findings (EBS statement ratings, ladder graphs and go-zones) were shared with leaders from a large federally qualified health center (FQHC) system (focusing on three clinic sites), to select and implement EBS over 12 months.

RESULTS

Concept mapping participants (n=23) sorted and rated statements, resulting in an eight-cluster solution: 1) Community education and outreach; 2) Advocacy and policy; 3) Data access/quality improvement monitoring; 4) Provider tracking/audit and feedback; 5) Provider recommendation/communication; 6) Expanding vaccine access; 7) Reducing missed opportunities; and 8) Nurse/staff workflow and training. The FQHC partner then selected to intervene on eight of 17 EBS statements in the "go-zone" for action, with three from "reducing missed opportunities," two from "nurse/staff workflow and training," and one each from "provider tracking/audit and feedback," "provider recommendation/communication," and "expanding vaccine access," which the research team addressed through the implementation of three multi-level intervention strategies (e.g., physician communication training, staff training and workflow assessment, audit and feedback of clinic processes).

CONCLUSIONS

Concept mapping provided a powerful participatory approach to identify multilevel EBS for HPV vaccination relevant to the local safety-net clinic context, particularly when several strategies exist, and prioritization is necessary. This study demonstrates how a clinic system benefited directly from the ratings and prioritization of EBS by multilevel clinic and community partners within the broader safety-net clinic context to identify and adapt prioritized solutions needed to advance HPV vaccine equity.

A National Approach to Promoting Health Equity in Cardiovascular Disease Prevention: Implementation Science Strengths, Opportunities, and a Changing Chronic Disease Context

In the USA, structural racism contributes to higher rates of cardiovascular disease (CVD) including hypertension, heart disease, and stroke among African American persons. Evidence-based interventions (EBIs), which include programs, policies, and practices, can help mitigate health inequities, but have historically been underutilized or misapplied among communities experiencing discrimination and exclusion. This commentary on the special issue of Prevention Science, "Advancing the Adaptability of Chronic Disease Prevention and Management Through Implementation Science," describes the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention's (DHDSP's) efforts to support implementation practice and highlights several studies in the issue that align with DHDSP's methods and mission. This work includes EBI identification, scale, and spread as well as health services and policy research. We conclude that implementation practice to enhance CVD health equity will require greater coordination with diverse implementation science partners as well as continued innovation and capacity building to ensure meaningful community engagement throughout EBI development, translation, dissemination, and implementation.

Disruptions to and Innovations in HPV Vaccination Strategies within Safety-Net Healthcare Settings Resulting from the COVID-19 Pandemic

The COVID-19 pandemic disrupted healthcare delivery within safety-net settings. Barriers to and facilitators of human papillomavirus (HPV) vaccination during the pandemic can inform future HPV vaccine strategies for underserved communities. Qualitative interviews (n = 52) between December 2020 and January 2022 in Los Angeles and New Jersey were conducted with providers, clinic leaders, clinic staff, advocates, payers, and policy-level representatives involved in the HPV vaccine process. Using the updated Consolidated Framework for Implementation Research we identified (1) outer setting barriers (i.e., vaccine hesitancy driven by social media, political views during the pandemic) and facilitators (e.g., partnerships); (2) inner setting clinic facilitators (i.e., motivation-driven clinic metrics, patient outreach, vaccine outreach events); (3) individual characteristics such as patient barriers (i.e., less likely to utilize clinic services during the pandemic and therefore, additional outreach to address missed vaccine doses are needed); (4) innovations in HPV vaccination strategies (i.e., clinic workflow changes to minimize exposure to COVID-19, leveraging new community partnerships (e.g., with local schools)); and (5) implementation strategies (i.e., multisectoral commitment to HPV goals). Pandemic setbacks forced safety-net settings to develop new vaccine approaches and partnerships that may translate to new implementation strategies for HPV vaccination within local contexts and communities.

Multilevel perspectives on school-based opportunities to improve HPV vaccination among medically underserved adolescents: Beyond school entry mandates

School-based HPV vaccination programs have improved vaccine uptake among adolescents globally. However, school-based HPV vaccination strategies in the United States (US) have mainly focused on school-entry mandates for vaccination, which have passed in only five states/jurisdictions. Many schools and school-based health centers (SBHCs) already provide health services to medically underserved adolescents and opportunities to improve disparities in HPV vaccine education and uptake are underexplored. This qualitative study of clinic and community members assessed potential opportunities within and outside schools to increase HPV vaccination. Data were generated from a larger mixed-methods study designed to understand experiences with HPV vaccination evidence-based strategies in medically underserved communities. The parent study included interviews and focus groups conducted with clinic (providers, clinic leaders, staff) and community (racial/ethnic minority parents, advocates, payers, policy representatives) members in Los Angeles and New Jersey between December 2020-January 2022. We created a reduced dataset of text related to schools/SBHCs (30 in-depth interviews, 7 focus groups) and conducted a directed content analysis. Participants indicated that schools and SBHCs are ideal venues for reaching medically underserved adolescents experiencing barriers to primary care access. Parents/providers expressed mutual interest in HPV vaccine administration/education in schools, but some advocates/policy participants experienced challenges due to increasing politicization of vaccines. Participants highlighted policies for expanding HPV vaccine education and administration in schools, including minor consent and increasing SBHC funding for HPV vaccines. More research is needed to explore existing infrastructure, partner motivation, and opportunities to improve HPV vaccination among medically underserved adolescents within schools beyond vaccine mandates.